Surgeons have historically delayed cholecystectomy in all patients with gallstone pancreatitis until normalization of pancreatic and liver enzymes and resolution of abdominal pain. However, the era of laparoscopic cholecystectomy (LC) has changed treatment approaches. Because of this, elective LC to remove the source of calculi is routinely performed during the same hospital admission to prevent further episodes.
In many cases, patients will undergo LC within 48 hours of hospital admission without waiting for pancreatic and liver enzyme levels to return to normal. Performing LC early has the potential to decrease length of hospital stay and minimize the unnecessary use of endoscopic retrograde cholangiopancreatography (ERCP). However, mild pancreatitis can be unpredictable. Some patients may undergo early operative intervention when the disease is actually evolving into a moderate-to-severe pancreatitis that may result in an exacerbation of their disease.
Comparative Data for Laparoscopic Cholecystectomy
A retrospective review that my colleagues and I had published in the Archives of Surgery addressed potential concerns about performing LC for mild gallstone pancreatitis. Results showed that the medial hospital length of stay was significantly less for patients receiving early LC (3 days) than for those receiving delayed LC (6 days). Early LC was also associated with decreased use of ERCP.
The observed decrease in length of hospital stay in our study was achieved without increases in adverse outcomes. No patients in either cohort died, and complication rates were similar for both study groups. Also, no patient with mild pancreatitis progressed to severe pancreatitis. For patients with mild gallstone pancreatitis, delaying an LC until laboratory values normalize appears to be unnecessary. Operating early in these patients is safe and should be considered the preferred approach.
Addressing Concerns of Mild Gallstone Pancreatitis
Despite emerging evidence supporting the safety and efficacy of early LC, there are still safety concerns to consider. One issue is whether or not mild gallstone pancreatitis can be accurately predicted when patients are admitted. Calculating the total Ranson score requires 48 hours. Instituting a policy of early LC might increase morbidity and mortality if patients are misidentified as having mild pancreatitis that later progresses to more severe disease. Another concern is that an early LC may lead to more cases of postoperative ERCP.
The safety of performing an early LC lies in how well patients are identified and excluded based on risk. Patients who may be at risk of progressing to a more severe pancreatitis include those with tachycardia, elevated serum urea nitrogen levels, or evidence of cholangitis at hospital admission. Previous research has verified the utility of these criteria in predicting mild pancreatitis. Provided that patients are carefully selected, our study further validates that LC for mild gallstone pancreatitis within 48 hours of admission can be performed safely.
Watch a rarely performed procedure, two port laparoscopic cholecystectomy, by Dr. R.K. Mishra:
Video provided by: Dr. RK Mishra
Readings & Resources (click to view)
Falor AE, de Virgilio C, Stabile BE, et al. Early laparoscopic cholecystectomy for mild gallstone pancreatitis: time for a paradigm shift. Arch Surg. 2012 Jul 16 [Epub ahead of print]. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1216541#.
West MA. Shifting surgical paradigms for cholecystectomy in mild gallstone pancreatitis. Arch Surg. 2012 Jul 16 [Epub ahead of print]. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1216547.
Acosta JM, Katkhouda N, Debian KA, et al. Early ductal decompression versus conservative management for gallstone pancreatitis with ampullary obstruction: a prospective randomized clinical trial. Ann Surg. 2006;243:33-40.
Rosing DK, de Virgilio C, Yaghoubian A, et al. Early cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay. J Am Coll Surg. 2007;205:762-766.
Aboulian A, Chan T, Yaghoubian A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. 2010;251:615-619.
Kelly TR, Wagner DS. Gallstone pancreatitis: a prospective randomized trial of the timing of surgery. Surgery. 1988;104:600-605.
Taylor E, Wong C. The optimal timing of laparoscopic cholecystectomy in mild gallstone pancreatitis. Am Surg. 2004;70:971-975.
Yaghoubian A, Aboulian A, Chan T, et al. Use of clinical triage criteria decreases monitored care bed utilization in gallstone pancreatitis. Am Surg. 2010;76:1147-1149.